Mohs Micrographic Surgery
WHAT IS MOHS SURGERY, AND WHY HAS MY PHYSICIAN CHOSEN THIS FORM OF TREATMENT?
Mohs surgery was developed by Dr. Frederic E. Mohs in the 1930s as a precise method for treating certain skin cancers. Since then, many technical improvements and refinements have contributed to making Mohs surgery the most advanced, precise, and effective treatment for an increasing variety of skin cancer types.
In Mohs surgery, cancerous tissue is removed layer by layer with a high degree of precision. Each thin layer is carefully identified and mapped by the Mohs surgeon, so its exact location can be pinpointed on the site where it was removed from. After careful preparation in the laboratory, the surgeon inspects each layer under the microscope. As long as cancer cells are seen, the surgeon continues to remove and examine tissue layers from that particular area of the wound. Because each layer is examined microscopically, Mohs surgery allows to trace out the entire extent of the tumor and provides the highest cure rate. In addition, because no healthy tissue is unnecessarily removed, and because your surgeon has been trained to perform reconstructive surgery (a branch of plastic surgery dedicated to reconstruction of skin defects caused by disease such as skin cancer), the best possible cosmetic results can be achieved with this technique.
WHAT ARE THE INDICATIONS FOR MOHS SURGERY?
- Achieving the highest success rate of all treatments for skin cancer (approaching 99%)
- Examining 100% of the surgical margins under the microscope
- Minimizing the amount of healthy tissue lost
- Maximizing the functional and cosmetic outcomes
WHAT ARE THE ADVANTAGES OF MOHS SURGERY?
- Skin cancers located on areas where preserving cosmetic appearance and function are important (such as the face, neck and hands)
- Skin cancers that have recurred after previous treatment or are likely to recur
- Skin cancers that are located within scar tissue
- Large skin cancers
- Skin cancers with ill-defined edges
WHAT DOES MOHS SURGERY INVOLVE?
- The entire procedure is performed under local anesthesia in our outpatient clinic.
- The first part of the procedure is performed in steps or cycles.
- Each step involves about 15 minutes of surgery to remove the cancerous tissue, after which you are directed to the waiting area. During this time, the tissue is prepared in the laboratory and examined under the microscope by the surgeon. This process takes about 1 hour or more.
- If cancerous tissue is seen, the process above is repeated until the last microscopic examination shows no remaining cancer cells or other suspicious changes.
- The number of steps depends on the size and depth of the cancer. The first part of the procedure ends once no more cancerous tissue is seen.
- The second part of the procedure consists in repairing the surgical wound that was created by removing the skin cancer.
- Since the laboratory portion of the procedure when the tissue is prepared can be very time consuming, please be prepared to spend the entire day in the office.
WHAT HAPPENS AFTER THE CANCER IS REMOVED?
Once the Mohs surgery is complete, there will be an open wound in the area previously occupied by the skin cancer. The method chosen to repair your wound will depend on its size, depth, shape and location. Dr. Godinez-Puig will discuss the repair options with you, with attention to providing the best functional and cosmetic results for your particular case.
Most often, the area will be repaired on the day of the surgery using stitches. Depending on the wound, it may be closed side by side (a technique called linear closure) or using a skin flap (skin moved into the wound from a neighboring site) or skin graft (patch of skin borrowed from another area) in order to provide the best result. In some selected cases, the wound is allowed to heal by itself without using stitches, which usually takes 6 to 12 weeks to fully heal. Once the area is repaired, you will go home with a large, bulky bandage that will remain in place for 24-48 hours. This helps reduce the risks of bleeding and infection.
HOW DO I CARE FOR MY WOUND AFTER SURGERY?
Most patients will have to wear a bulky bandage for 24-48 hours after the surgery. It is extremely important to keep this bandage completely dry and undisturbed for the recommended time period. Failure to do so can increase your chance of significant postoperative bleeding, which can in turn alter the initial healing process.
Once the bandage is removed, it is important to care for the wound twice a day to achieve adequate healing following the detailed wound care instructions that will be provided to you on the day of the surgery.
WILL THERE BE ANY AFTER EFFECTS FROM MY SURGERY?
Pain. Discomfort, if it should occur with this procedure, is usually mild and can be managed with over-the-counter Extra Strength Tylenol. Do not take aspirin-containing products or medications similar to Motrin or Advil (see the pre-operative instructions in this packet for an extensive list of such medications to avoid), as these may promote bleeding and bruising, which may significantly alter initial wound healing. If unusual pain is anticipated, we will provide a prescription for a more potent pain medication.
Bleeding. A bulky bandage will be applied to the wound and should be left in place for 1 to 2 days to minimize swelling and bleeding. Although some minimal bleeding is typical and expected, brisk bleeding after the surgery is not very common. You should completely avoid physical activity for 2 weeks following the surgery, as well as lifting and bending for 72 hours after the surgery to prevent unnecessary bleeding and swelling and to optimize initial wound healing.
Initial redness and bumpy appearance. The wound may appear red and demonstrate firm, lumpy areas initially. This is absolutely normal and expected, as it is related to normal wound healing and to the suture material that was strategically placed to bring the edges of the wound together. Redness and bumpy appearance should gradually resolve within 12 weeks after the surgery.
Swelling and bruising. Swelling and bruising are very common following Mohs surgery, particularly when performed around the eye region. Surprisingly, these may continue to worsen for 3 or 4 days before they start resolving, which will take about 2 to 3 weeks in total.
Infection. Wound infections can occur unexpectedly but are usually easily treated with oral antibiotics. Signs of infection may include severe, unexpected worsening redness and tenderness on the wound site, as well as fever, pus or greenish discharge, and a wound site that is very warm to touch.
Itching and associated redness. Itching and redness around the wound, especially in areas where adhesive tape has been applied, are common. They can be the result of local irritation or a minor allergic reaction due to the glue present in the tape.
Numbness. You may experience numbness, tingling, or unusual sensations at or near the scar. This is normal, and results from minor nerve endings being injured during surgery and may take 6 to 12 months to improve.
Scar. Every single wound will naturally cause the formation of a scar of some sort. Although every attempt will be made to maximize wound healing, and to minimize and hide the resulting scar, this may not always be completely possible. The extent of scarring and the appearance of the scar depends on a number of factors, all of which carry an important role. These not only include the location, size and depth of the cancer, as well as the type of repair that is ultimately performed, but also how well one adheres to the postoperative instructions, if one has certain conditions such as diabetes or is required to take certain medications such as steroids, and how well one’s body undertakes the wound healing.
If you would like to learn more about Mohs click on the link below to watch a short video presentation posted by the American College of Mohs Surgery (ACMS): https://youtu.be/F6TxdvjPk5I